Breastfeeding Support-Doulas: Boundaries and Benefits

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I’ve spent my working life thinking about boundaries in one capacity or another and have been through the pain of working out why it’s important for me to understand where my role begins and ends as a doula, breastfeeding counsellor and doula course leader and believe me, sometimes it’s difficult to work out ‘who’ I am at any given moment!

One very bright, reflective and sensitive trainee emailed me recently with some wonderful questions. I reckon they make a great basis for some thoughts on boundaries, so here goes.

“I am having a bit of trouble distinguishing my role as a doula and peer supporter and was wondering whether you might be able to clarify…..It’s such a fine line to supporting and suggesting and advising…..”

Too right it is! I’ve learnt that the foundation of supporting people are the same, whether we are birth doulas, helping with breastfeeding, being a good friend or neighbour or giving effective postnatal support. Where is this ‘fine line’ between ‘advice’ and suggestion?

We need some help with defining these types of approaches, I think.

Some synonyms of advice: recommend, urge, prescribe

So, when we give advice,we are more or less pushing our own agenda on the person we are talking to – in fact may of the words we use when giving advice are called ‘modal verbs’. Modals of advice are verbs like:

Must – “You must top-up with formula”, “You must stop feeding him”. These statements imply necessity, obligation or prohibition.

Ought to -” You ought to feed her more often”. This is saying what we consider to be right or correct.

Should – “You should sort out this problem at once.” Again, this is implying that we know what is right or correct or recommending action.

So what’s wrong with using words that have a sense of obligation, order or recommendation? Why is is unhelpful to urge, coerce, or imply that we know best?

Well, I think you know the answer to that already. You are doulas! You know that’s not what we want to achieve within a relationship we are building that empowers the mother and enhances her sense of self-sufficiency and pride in her mothering.

So let’s look at what we can achieve by being careful with our language:

“Baby gaining weight perfectly but not “settling” – seems constantlyhungry allthe time and mum is exhausted and feels milk is depleted. I have referredonto aBFC / LC but can we suggest things like putting baby to breast moreoften,having a babymoon, compressions, Fenugreek / galactagogues / pumping toincrease supply / co-sleeping or is this out of our remit? i.e. whathappens ifthey co-slept and then something happened to the baby and it was oursuggestion?”

OK so let’s tease this out a little. Yes, this lady needs signposting – that is clear and simple and a gift to her that cannot be underestimated! What’s wrong with offering the information on building supply? Nothing whatsoever, as long as you are not giving advice! Urging a course of action may well turn out to be necessary, but are you willing and able to bear that responsibility? What if something happened as a result of your advice that made it difficult for you to sleep at night? Horrid! And personally, that’s why I’m a doula and not a midwife – I don’t want that responsibility!

If you are also a birth doula, what do you do if you are with a woman at home in early labour and she soaks a pad with fresh red blood? Your experience and knowledge may tell you that this is probably a very bloody show, but you know the right thing to do – offer information and suggest she calls the midwife for advice.

If you are postnatal doula and you see the baby is getting increasing yellow, do you advise increased breastmilk and sunlight, or do you do the right thing and ask the mother what the midwife has said about the jaundice and find out if the mum needs any more informational support. Signposting to a BFC or LC may well help to provide the mum with the time and in-depth counselling she may need.

This is doula support. This is Peer Support.

Right next part of the trainee’s question:

“If mums were pumping to increase supply, I presume we are qualified to suggest different ways of feeding i.e. cup / finger / SNS / bottle and then let mum make the decision which route to go down.”

I think we’re getting a bit mixed up here, between ‘peer’ or ‘lay’ support and ‘expert advice’. There is just not enough information here to make a judgement about what WOULD be an appropriate suggestion. There is a big difference between a mum who is pumping to increase a ‘just about adequate’ supply, with a baby who is latching effectively and drinking efficiently, and a mum whose baby is sleepy or tongue-tied, for example, not latching at all or has a weak suck and is losing weight…these are potentially serious, medical complications and situations that even a BFC
will need others to help with (an LC, a tongue-tie divider, GPs, midwives and paediatricians may all have a part to play in supporting the dyad effectively).

We are quite comfortable with the definition of a doula – the offering of emotional and practical support ONLY. The Peer Breastfeeding Supporter role is no different, in that we are there to support normality. Now, in reality, we are often working with mums whose circumstances have veered off the ordinary, normal course. Our first step is to signpost, (either to people or written sources or both) and then support our client in her chosen path. It seems to me that if our signposts have been good quality, effective ones,; it wouldn’t be up to the doula to suggest feeding methods like this – the Infant Feeding Midwife, BFC or LC would have talked her through her options and how to achieve them. We as the doulas are merely there to support her through the decision-making process and offer practical help to implement her decisions.

So, again, no difference between the normal doula role and the BF Peer Supporter.

Next question:

“Often things have been said on forums to put baby to breast more oftenand thenreduce the amount of formula top-ups given, which yes, makes sense, butwhathappens if this doesn’t work and baby starts loosing weight?”

Exactly! This is NOT for the doula to advise! She might make a suggestion or offer information only along the lines of:

“It says in this book that more frequent feedings will enhance supply – would you like to read it?”

Or – “Many mums find that if they offer the breast first, and frequently
that their supply builds and they can begin to reduce the formula – would
you like to talk to someone about it?”

Or – “It sounds like you’d like to phase out the formula. Have you
discussed increasing the number of breastfeeds with anyone? How do you
feel about that?“

And always, always, we talk to the mum about our role:

“Remember, I am only here to support you in your decisions. I can’t tell you what to do. You are her mother and you know best what is right for you and your baby. I can help you find information and people to talk to, but at the end of the day, your decisions are your responsibility because you are the expert on your own child”

So the next part of the trainee’s question has already been answered:

“Suggesting the harvey karp method i.e. 5 ‘Ss’ (swaddling, side/stomachposition, shushing, swinging, and sucking) but guidelines are to put babyto sleep on back and then you suggest this (ie. side / stomach position).I know all these things are for the mum to decide, but my point is thatif you suggest it and something happens, then what, as we have beenemployed in a ‘professional’ capacity so they do believe what you say?”

We are signposting only! If we lend the Karp book, we do so with an important caveat:

“There are suggestions in this book that appear to contradict some of the official guidelines. I’m not endorsing this approach or saying I think you should take his advice. Some mums I’ve worked with have found it to be useful, but you must do your own research and work out for yourself what you want to do.

In my experience, most parents take bits and bobs that work for them, and discard the stuff that doesn’t work for them, or goes against their instincts. I know you’ll do what’s best for you because you’re such a brilliant mum.”

Our clients do listen to us. They take on board what we say. They thank us for our advice! So it’s so important to be careful. It’s not what we say and do, it’s HOW we say it and HOW we do it. Ask yourself a few questions each time:

Is this normal and healthy?

Am I willing to take responsibility for this mother and baby?

Is there someone more experienced, with more in depth knowledge than me who could help this client?

Has this situation moved outside the realm of normality?

What would I do if this were labour? Or another kind of postnatal situation?

What do I want to say and how can I phrase it?

Doulas and Peer Supporters work out their boundaries by knowing what they know and knowing what they DON’T KNOW or have little experience of.

Dangerous or ineffective support is given by people who don’t know what they don’t know.

Know the difference and you’ll be dedicated doulas and perfect peer supporters.